Benefits Manager Policy Disrupts Patient-physician Decision Making for Breast and Prostate Cancer Radiation Treatments

October 2, 2020 — Radiation oncologists expressed serious concerns about a new private insurance coverage policy that could undermine patient-centered care for two of the most common cancers in the United States. Leaders of the American Society for Radiation Oncology (ASTRO) urge eviCore, a radiation oncology benefits management company, to halt and make meaningful changes to a new policy for radiation therapy coverage. Under the new policy, EviCore mandates that most breast and prostate cancer treatments use a shorter, hypofractionated radiation therapy regimen even if it runs counter to a physician’s clinical recommendation.

While ASTRO guidelines generally support hypofractionation for the treatment of breast and prostate cancer, these guidelines stress that shared decision making between the physician and patient should come first. While many breast and prostate patients are candidates for hypofractionated treatments, some patients have certain clinical characteristics and situations where longer course treatments are appropriate.

"We recognize eviCore's intent to support national clinical guidelines, but these new requirements are a misuse of those recommendations. Broad application of this heavy-handed dictate is an overreach that will interfere with shared decision making between doctors and patients. Insurance companies should not be the ones to decide how our cancer patients are treated," said Theodore L. DeWeese, M.D., FASTRO, Chair of the ASTRO Board of Directors.

The guidance could also harm patients who are not candidates for short-course radiation therapy, such as those with certain immunologic conditions or previous radiation therapy. ASTRO experts in breast and prostate cancer have shared recommendations with the benefits manager to modify the policy, including lists of clinical indications where the physician and patient should have significant discussion about the pros and cons of utilizing shorter-course treatment. ASTRO remains open to working with eviCore to modify these policies to support patient-centered care and personalized decision-making.

The timing of the guidance is also questionable, as the new mandates create yet another burden on physicians and medical practices already contending with the COVID-19 pandemic. ASTRO research shows that many radiation oncology practices face numerous challenges as a result of the pandemic, including financial shortfalls, staff reductions and substantially fewer patients being referred to radiation therapy.

ASTRO supports greater radiation oncology adoption of clinical guidelines supporting hypofractionation, but one-size-fits-all insurance company mandates are not the solution. Instead, ASTRO urges private payers to work with the Society to implement value-based care through alternative payment models (APMs).

"APMs are designed to be a better, smarter way of managing utilization. By paying a flat rate that bundles services, physicians are incentivized to provide the appropriate care, while allowing the physician to work with the patient to decide what is the most appropriate treatment. As Medicare moves to adopt a value-based model for radiation oncology, private insurers should look to implement a similar payment structure that could reduce costs while supporting high quality care for patients," said Dr. DeWeese.

ASTRO previously called on radiation oncology benefits management companies to end restrictive coverage practices in the form of prior authorization requirements that create unnecessary delays and interfere in care decisions. In a 2019 survey of more than 700 radiation oncologists, nearly all (93%) said their patients experienced treatment delays, and a third said the average delay lasted more than five days. ASTRO is currently fielding a follow-up survey, and preliminary results suggest the problem of prior authorization has been exacerbated by the pandemic.

"Before COVID-19, ASTRO members said prior authorization was the biggest challenge they faced in daily practice," said DeWeese. "The new hypofractionation policy from eviCore is unfortunately another example of the health insurance industry subjugating physician judgement and removing patient choice from the cancer care process."

ASTRO supports the Improving Seniors Timely Access to Care Act (HR 3107), which has more than 230 bipartisan cosponsors in the House, as a critical first step to rein in excessive prior authorization practices.

For more information: www.astro.org